Provider Demographics
NPI:1326044967
Name:ASSOCIATED GASTROENTEROLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:ASSOCIATED GASTROENTEROLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERI
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-778-1300
Mailing Address - Street 1:1211 W LA PALMA AVE
Mailing Address - Street 2:STE 306
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-2811
Mailing Address - Country:US
Mailing Address - Phone:714-778-1300
Mailing Address - Fax:714-778-0303
Practice Address - Street 1:1211 W LA PALMA AVE
Practice Address - Street 2:STE 306
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2811
Practice Address - Country:US
Practice Address - Phone:714-778-1300
Practice Address - Fax:714-778-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ83646ZMedicaid
CAZZZ83646ZMedicaid
CAW2945AMedicare PIN